American Board of Medical Specialties

Training of a Specialist

The training of a specialist begins after the doctor has received the M.D. degree from a medical school, in what is called a residency. Resident physicians dedicate themselves for three to seven years to full-time experience in hospital and/or ambulatory care settings, caring for patients under the supervision of experienced specialists. Educational conferences and research experience are often part of that training. In years past, the first year of post-medical school training was called an internship, but is now called residency.

Licensure, the legal privilege to practice medicine, is governed by state law and is not designed to recognize the knowledge and skills of a trained specialist. A physician is licensed to practice general medicine and surgery by a state board of medical examiners after passing a state or national licensure examination. Each state or territory has its own procedures to license physicians, and sets the general standards for all physicians in that state or territory.

Who Credentials a Specialist and/or Subspecialist?

Specialty boards certify physicians as having met certain published standards. There are 24 specialty boards that are recognized by the American Board of Medical Specialties (ABMS) and the American Medical Association (AMA). You will find a brief description of each specialty/subspecialty in the complete “PDF” version of this document. Remember, a subspecialist first must be trained and certified as a specialist.

In order to be certified as a medical specialist by one of these recognized boards, a physician must complete certain requirements. Generally, these include:

1. Completion of a course of study leading to the M.D. or D.O. (Doctor of Osteopathy) degree from a recognized school of medicine. 2. Completion of three to seven years of full-time training in an accredited residency program designed to train specialists in the field. 3. Many specialty boards require assessments and documentation of individual performance from the residency training director, or from the chief of service in the hospital where the specialist has practiced. 4. All of the ABMS Member Boards require that a person seeking certification have an unrestricted license to practice medicine in order to take the certification examination. 5. Finally, each candidate for certification must pass a written examination given by the specialty board. Fifteen of the 24 specialty boards also require an oral examination conducted by senior specialists in that field. Candidates who have passed the exams and other requirements are then given the status of Diplomate and are certified as specialists. A similar process is followed for specialists who want to become subspecialists.

All of the ABMS Member Boards now, or will soon, issue only time-limited certificates which are valid for six to ten years. In order to retain certification, diplomates must become “recertified,” and must periodically go through an additional process involving continuing education in the specialty, review of credentials and further examination. Boards that may not yet require recertification have provided voluntary recertification with similar requirements.

Accreditation Council for Continuing Medical Education (ACCME)

This is the successor organization to the Liaison Committee on Continuing Medical Education and the Committee on Accreditation of Continuing Medical Education of the American Medical Association. It was organized to promote, develop, and encourage principles, policies, and standards for continuing medical education and to apply them to the accreditation of institutions and organizations offering continuing medical education. It has the responsibility for accrediting institutions and organizations offering continuing medical education and developing standards by which state medical societies will accredit local institutions and organizations. The sponsoring members (parents) of the ACCME are the:

• American Board of Medical Specialties (ABMS) • American 1-lospital Association (AHA) • American Medical Association (AMA) • Association for Hospital Medical Education (AHME) • Association of American Medical Colleges (AAMC) • Council of Medical Specialty Societies (CMSS) • Federation of State Medical Boards (FSMB).

Accreditation Council for Graduate Medical Education (ACGME )

This is the successor organization to the Liaison Committee on Graduate Medical Education which was organized to develop effective methods to evaluate and promote the quality of graduate medical education and to provide for the accreditation of programs in graduate medical education according to established standards. The ACGME is responsible for the accreditation of residency training programs through the 25 Residency Review Committees (RRC’s). The RRC;s process the actual accreditation of residency programs, but the ACGME approves standards and deals with appeals and administrative issues. The sponsoring organizational members of the ACGME are the:

• American Board of Medical Specialties (ABMS) • American Medical Association (AMA) • American Hospital Association (AHA) • Association of American Medical Colleges (AAMC) • Council of Medical Specialty Societies (CMSS).

Educational Commission for Foreign Medical Graduates (ECFMG)

The ECFMG screens international medical graduates to verify their qualifications for admittance to residency training in the United States through a certification process.

Certification by the ECFMG is accomplished by an examination of credentials, a test of knowledge of medical matters through administration of Steps I and II of the United States Medical Licensing Exam (USMLE), and a test of facility in the English language. The Educational Commission for Foreign Medical Graduates was formed by merger of the Educational Council for Foreign Medical Graduates and the Commission on Foreign Medical Graduates in 1974. The ABMS appoints two representatives to the Board of Trustees of the ECFMG.

Council of Medical Specialty Societies (CMSS)

The CMSS is an umbrella organization comprised of the major specialty societies that correspond to the Member Boards of the AJ3MS. The specialty societies are involved in issues related to specialty practice. The societies are also interested in education and serve as one of the sponsors of the Residency Review Committees (RRC’s) that accredit residency programs in their specialty.

Federation of State Medical Boards (FSMB)

The FSMB serves as the national voluntary association of all United States licensing and disciplinary boards. The FSMB promotes the adoption, maintenance and advancement of effective and uniform standards for licensure and discipline in medicine and the healing arts.

ABMS Statement on “Board Eligible”

Because of continuing confusion about the term “board eligible’, the American Board of Medical Specialties (ABMS) wishes to reiterate its position about that term. The specific term ‘board eligible’ has been given such diverse meanings by different agencies that it has lost its usefulness as an indicator of a physician’s progress toward certification by a specialty board. Furthermore, because some candidates have used the term year after year while making no perceptible progress toward certification, it has sometimes been accepted improperly as a permanent alternative to certification. The requirements for admission to the certification process change from time to time, making the term “board eligible” equally susceptible to changes in meaning. For these reasons, the ABMS recommends to its Member Boards that the use of the term “board eligible” be disavowed. Instead, the Boards are urged to respond to inquiries by stating an individual’s precise position in the certifying process.

For all except those recently certified as specialists by an ABMS Member Board and except for a very small number of specialists who do not wish to be listed, the fact of certification may be determined from one of the ABMS Directories of Certified Specialists [The Official ABMS Directory of Board Certified Medical Specialists].

Information about the certification status of any individual may be sought from the respective specialty board. Since most specialty boards now require written authorization for release of information, inclusion of a signed authorization should expedite the response. In most cases, the board will respond by indicating a physician’s position in the process toward certification, if known.

Information about whether a physician has satisfactorily completed a residency program accredited by the Accreditation Council Graduate Medical Education (ACGME ) should be sought from the program director of the residency program presumed to have been completed.

Inquiries regarding the general process of certification of specialists may be addressed to the ABMS. Questions concerning the status of individuals or requirements of an individual specialty board should be addressed to that board.

Adopted by the ABMS Assembly, 3/18/77 Revised, 3/21/85

Definition of Primary Care

Primary care is that form of medical care delivery which encompasses first contact care and the assumption of continuing responsibility for the patient in both health maintenance and the management of illness, be the problems biological, behavioral or social. Primary care has five essential attributes, i.e., accessibility, comprehensiveness, coordination, continuity, and accountability. It is personal in nature involving a unique relationship, interaction and communication between the patient and the primary care physician and also between the primary care physician and the appropriate other specialty care providers, consultants and/or community resources.

Adopted by the ABMS Assembly, 3/1 8/87

ABMS Statement on “Delineation of Clinical Privileges”

The clear delineation of clinical privileges of medical staff members in health care organizations is intended to improve the quality of care by identifying professional capabilities of physicians and other practitioners, thus providing additional assurance that individual practitioners are competent to fulfill the delivery of care for which they are responsible. The Joint Commission on Accreditation of Healthcare Organizations, through its published hospital accreditation standards and its survey procedures, has strongly promoted the appropriate delineation of clinical privileges for each medical staff member and qualified practitioner based on training, experience, and demonstrated current competence. The ABMS encourages and supports these efforts.

It is recognized that there are various methods for delineating clinical privileges. In making the determination of what privileges a practitioner will be permitted to exercise, medical specialty certification or subcertification should be considered as only one of several valid and important criteria. It should be emphasized that there should be no specific requirement by a health care organization for a diplomate in a recognized specialty to be certified in a subspecialty of that field in order to include aspects of that subspecialty within the range of privileges.

The ABMS believes that the delineation of clinical privileges is an institutional responsibility, vested in the medical staff and the governing body of the health care organization and is distinctly separate from the process of medical specialty certification, a responsibility of specialty boards. The lines of delineation of hospital privileges and of board certification are not necessarily identical.

Adopted by the ABMS Assembly, 3/I 8/77 Revised 9/21/95

Policy Statements

The Purpose of Certification

The intent of the certification of physicians is to provide assurance to the public that a physician specialist certified by a Member Board of the American Board of Medical Specialties (ABMS) has successfully completed an approved educational program and an evaluation process which includes an examination designed to assess the knowledge, skills, and experience required to provide quality patient care in that specialty.

Adopted by the ABMS Assembly, 3/19/87 Revised 9/23/93

Changes in Wording of Certificates

It is declared to be the policy of the American Board of Medical Specialties that any change in the wording on an existing certificate which refers to or names the areas of practice or the areas of training or specialization of the holders of such a certificate shall constitute a substantive modification of an existing type of certificate and shall be subject to the provisions of Section 10.4 of the Bylaws of the ABMS.

Adopted by the ABMS Assembly, 3/1 7/88

Certification of non-MDs

While the American Board of Medical Specialties acknowledges the continuing authority of the American Board of Medical Genetics and the American Board of Radiology to certify non-physicians, hereafter the ABMS will not authorize the Member Boards of the ABMS to certify non-physicians. Adopted by the ABMS Assembly, 9/22/94

ABMS Statement on “Board EIigibIe”

Because of continuing confusion about the term “board eligible”, the American Board of Medical Specialties (ABMS) wishes to reiterate its position about that term. The specific term “board eligible” has been given such diverse meanings by different agencies that it has lost its usefulness as an indicator of a physician’s progress toward certification by a specialty board. Furthermore, because some candidates have used the term year after year while making no perceptible progress toward certification, it has sometimes been accepted improperly as a permanent alternative to certification. The requirements for admission to the certification process change from time to time, making the term “board eligible” equally susceptible to changes in meaning. For these reasons, the ABMS recommends to its Member Boards that the use of the term “board eligible” be disavowed. Instead, the Boards are urged to respond to inquiries by stating an individual’s precise position in the certifying process.

Information about whether a physician has satisfactorily completed a residency program accredited by the Accreditation Council for Graduate Medical Education (ACGME) should be sought from the program director of the residency program presumed to have been completed.

Adopted by the ABMS Assembly, 3/18/77 Revised, 3/21/85

Definition of Primary Care

Primary care is that form of medical care delivery which encompasses first contact care and the assumption of continuing responsibility for the patient in both health maintenance and the management of illness, be the problems biological, behavioral or social. Primary care has five essential attributes, i.e., accessibility, comprehensiveness, coordination, continuity, and accountability. It is personal in nature involving a unique relationship, interaction arid communication between the patient and the primary care physician and also between the primary care physician and the appropriate other specialty care providers, consultants and/or community resources.

Adopted by the ABMS Assembly, 3/1 8/87

ABMS Statement on “Delineation of Clinical Privileges”

Adopted by the ABMS Assembly, 3/18/77 Revised 9/21/95

ABMS Statement on “Relationship Between Specialty Board Certification and Medical Licensure”

The American Board of Medical Specialties (ABMS) encourages its Member Boards to require unlimited medical licensure as a prerequisite for certification and maintenance of such licensure for recertification. This is one of several criteria the boards may use in satisfying questions as to the moral character arid legal standing of candidates in their respective states. A number of state licensing boards now accept or consider certification by a specialty board in lieu of their own requirements for licensure.

Although the ABMS recognizes the right of each state to establish its own regulations, ABMS discourages the substitution of certification for licensure requirements because it has led in some cases to licensure by specialty. The ABMS opposes licensure by specialty for the following reasons:

1. It is convinced that every specialist should maintain basic knowledge and skill in the broad aspects of medical care. 2. The boundaries between specialties are often hazy and overlapping. State governments should not define such boundaries lest transgressions be punishable under the law. The ABMS believes that practice restrictions should be determined only by the judgment of individual physicians, the medical staffs of hospitals, or the customs of the community in which the doctor practices. 3. Licensure by specialty will impose serious handicaps upon physicians who seek interstate endorsement of licenses so obtained. Very few state licensing boards will endorse licenses obtained by specialty certification. 4. Requiring a physician to limit his or her practice to a specialty could increase the cost of medical care as it might entail needless consultations with unnecessary repetition of tests with concomitant increases in patient’s bills.

Furthermore, the laws of many states either permit or require licensing boards to establish rules and regulations mandating continuing medical education (CME) for reregistration of medical licenses. Some state boards will accept specialty board recertification as satisfying their CME requirements. Although the ABMS recognizes the right of each state to establish its own regulations, it discourages the acceptance of recertification in lieu of the state’s reregistration requirements for the following reasons:

1. There is danger that this could encourage a trend toward licensure by specialty. 2. As recertification is private and voluntary, it is undesirable to adopt this as a substitute for the public and legal requirements of licensing boards.

Adopted by the ABMS Assembly, 1/28/77 Revised and reaffirmed by the ABMS Assembly, 3/20/97

The Significance of Certification in Medical Specialties:

A Policy Statement

A. General Principles Medical specialty certification in the United States from its inception has been a voluntary process. Since the establishment of the first nationally recognized medical specialty board in 1917, some physicians have elected to seek formal recognition of their qualifications in their chosen specialty fields by presenting themselves for examination before specialty boards comprised of their professional peers. The definitions of each of the specialties and of the educational and other requirements leading to eligibility for board certification have been developed by consensus within the medical profession and, to date, the certification of a medical specialist has remained separate and distinct from licensure by civil authorities of professionals qualified to practice medicine within their jurisdictions.

The voluntary nature of specialty certification is attested to further by the fact that as of December 31, 1973, only 46 percent of the 308,127 physicians not in training included in the national registry of physicians maintained by the American Medical Association are diplomates of one or more of the 22 [currently 24] Member Boards of the American Board of Medical Specialties.(1) Yet, as Levit, et al., have recently demonstrated, the trend toward specialty board recognition is accelerating and during the current decade “virtually all United States graduates will undertake residency training and seek specialty certification. (2)

The growth in medical specialty certification must be differentiated from the parallel increasing trend of physicians to voluntarily designate special areas of interest or areas of special practice to which they devote the largest segment of their professional time, whether or not they are diplomates of the 22 [currently 24] Member Boards of the American Board of Medical Specialties. For such purposes the American Medical Association has expanded its list of specialty designations to 67 categories to assist the individual physician in describing his primary field of medicine for listing in the American Medical Directory. There are no professional or legal requirements for a licensed physician to seek specialty board certification in order to offer professional services in a specialty.

Many thoughtful observers, both within and outside of the profession, caution that the progressive fragmentation of medicine into more and more medical specialties and subspecialties is contrary to the best interests of the public. Nevertheless, the established specialty boards as well as the American Board of Medical Specialties itself increasingly are facing concerted pressures to offer certification in additional specialty or subspecialty categories. This is occurring despite the fact that accredited educational programs and the evaluative examinations on which general certifications are based assign appropriate emphasis to each of the subspecialties or areas of special competence identified with the corresponding primary field. Accordingly, diplomates holding general certification normally acquire, to a greater or lesser degree, all of such special competencies in their educational and specialty practice experience.

There is no requirement or necessity for a diplomate in a recognized specialty to hold special certification in a subspecialty of that field in order to be considered qualified to include aspects of that subspecialty within a specialty practice. Under no circumstances should a diplomate be considered unqualified to practice within an area of a subspecialty solely because of lack of subspecialty certification.

Specialty certification in a subspecialty field is of significance for physicians preparing for careers in teaching, research, or practice restricted to that field. Such special certification is a recognition of exceptional expertise and experience and has not been created to justify a differential fee schedule or to confer other professional advantages over other diplomates not so certified.

Concentration of practice in a field acceptable for the award of a certificate of special competence may connote expertise in the use of special devices, techniques, or methodologies associated with that field. However, recognition of a subspecialty by the American Board of Medical Specialties must be based on broader principles than such expertise alone. The essential nature of an accepted discipline relates to the body of knowledge or philosophy of action which it encompasses.

Physicians wishing voluntarily to limit their practices to the use of special devices and techniques or methodologies are free to do so, but if they wish to have specialty board certification, it should be within one of the specialties which includes the use of the related device, technique, or methodology, along with the more basic body of knowledge that is applied through their use.

Approval of a new area for special certification, sometimes identified as subspecialty certification or as certification of special competence, signifies that there has been a thorough and critical review of the proposals by the Committee on Certification, Subcertification, and Recertification, by the Executive Committee, and by the full Membership of the ABMS. This critical review includes recognition of the fact that such approval is accompanied by related decisions by educational institutions to provide training in such areas.

B. The Responsibility for Self-Regulation of Specialization in Medicine The ABMS shall have the responsibility to establish standards for the approval of new specialties and subspecialties. In fulfilling this responsibility, the ABMS will develop generic criteria for admission to the certification process and develop guidelines for Boards to conform to generally accepted standards.

The purpose of subspecialty certificates is to establish standards of preparation to be required of those individuals who wish to provide care to the public in a subspecialty area that the ABMS has determined is of sufficient importance to be so designated.

The ABMS shall review on a regular basis all basic board certifications and all subspecialty certifications. The purpose of the review is to ensure that commonly shared goals and standards of the ABMS are maintained and that the original purposes of certification continue to exist and continue to be met. Initiation of an action by a Member Board to withdraw existing certification in a presently established subspecialty should be encouraged if appropriate.

It is the policy of the ABMS that recognition of subspecialty certification should be primarily for individuals who are devoting a major portion of their time and efforts to that restricted special field. Subspecialty certification should be granted only after education and training or experience in addition to that required for general certification in the discipline.

Adopted by the ABMS Assembly, 9/18/75 Revised 9/23/93

(I) Medical School Alumni, Aspen Systems Corporation, Rockville, MD, 1975. (2) Levit, E.J., Sabshin, M., and Mueller, C.B., Trends in Graduate Medical Education and Specialty Certification, : N Eng1 J Med 290:545-549, March 7, 1974.

American Board of Medical Specialties®